pediatrics Flashcards
most common peds emergencies and their tx
om-amoxicillin 80- 90mg/kg/d
Viral URI-acetaminofen, hold the cough syrup
acute gastro -oral hydration
fluid for shock
Boluses of 20ml/kg in shock
fluid for dehydration
Boluses of 10ml/kg in dehydration
Re-assess after each bolus
IOs can be done where? why would you
is coding
flat part of tibia and the humorous
what are the reasons physicians miss illness
wellness bias
pressure to be productive
desire to avoid avoid unnecessary or expensive tests.
temp greater than in Peds is a
i. Temp greater than 38C
Temp less than ___ correlates to a low risk for bacteremia.
Temp less than 39C (102.2 F) correlates to a low risk for bacteremia.
common sites of fever for a pediatric patient include (4)
a. Otitis Media
b. Pharyngitis-URI
c. Pneumonia
d. Acute Gastro-enteritis
when assessing toxic appearance in a ped (4)
pale-check mucosa
poor profusion
-a. Cyanosis, mottled skin
respiratory distress-
a. Tachypnea, shallow breathing
altered mental status
-a. Poor eye contact, feeding, failure to respond to caregivers.
Neonates, age 0-28 days w/ fever 38c or more
what’s the workup (6)
i. Admit them all. Let the pediatrician sort them out.
- CBC
- Blood cultures
- Urinalysis
- Urine culture
- Lumbar puncture
- Parenteral antibiotics
when would you do a CXR in a admitted neonate
a. Cough
b. Tachypnea
c. O2 sat less than 95%
when woudl you do stool studies in a neonate
- Stool studies if diarrhea
Fever, age 28-90 days work up for a child with a fever
i. CBC
ii. Urinalysis, gram stain if available
iii. Urine culture
iv. Blood culture
what would you want to consider in a 28-90 day work up for a child with a fever
- Lumbar puncture, (some authors say all patients in this category)
- Chest x-ray
- Stool studies
- Fecal leucocyte count and stool culture
Fever without a source: who can go home is based on
Rochester criteria
for bacteremia risk in infants 28-90 days old, with fever
Overall risk of occult bacteremia in well appearing febrile infant
- Overall risk of occult bacteremia in well appearing febrile infant: 7-9%
- If all Rochester Criteria met, risk is less than 1%
labs associated with rochester criteria
a. WBC 5-15k; bands less than 1.5k
b. Urine less that 10wbc/hpf, or neg leukocyte esterase/nitrate or negative gram stain of unspun urine
c. Fecal smear less than 5wbc/hpf
If reliable caregivers and access to follow-up in office or ED for 28-90 day old infant
a. Blood culture
b. Urine culture
c. Consider LP and ceftriaxone 50mg/kg IV
d. Re-evaluate in 24 hours
e. Admit positive blood culture or febrile UTI
f. Treat afebrile UTI as outpatient.
3-36 months oldFever without source-
- Occult UTI
what sxs is associated with a higher risk of UTI
a. 2% of FWS in children under 5yrs
b. 6-8% of girls; 2-3% of boys under 12mo
c. Higher temp correlates with increased likely hood of UTI
Untreated UTI can lead
to kidney damage and renal failure in adulthood
3-36 months oldFever without source-
what would you suspect
occult UTI
occult PNA
occult bacteremia
what reduces the likelihood of occult PNA
b. Heptavalent pneumococcal vaccine reduces likelihood of pneumonia
what is the major signs of PNA
tachypnea
Positive x-ray in 26% of children with temp >39C or wbc>20k
3% of cases of Pneumococcal bacteremia progress to
meningitis
3-36 mo with toxic apperance workup
a. Admit
b. Septic work-up
c. IV antibiotics
Non toxic, Temp <39c 3-36 mo workup
a. No tests
b. Acetaminofen
c. Return if fever persists >48 hours or if condition deteriorates.
Nontoxic with temp> 39 C
when would you evaluate Urine
Evaluate urine for
all females < 12 months old;
uncircumcised males < 12 months old
circumcised males < 6 months old.
b. If UTI is found: culture urine, treat with antibiotics and and follow up in 48 hours.
when would you get a CXR in a non toxic kid wiht a temp >39
Chest x-ray if O2 sat < 95%,
tachypnea, rales, temperature
≥39.5°C and WBC count ≥20,000
febrile seizures are usually lesss than
Generalized seizure, less than 15 minutes duration associated with fever spike
is there a risk of epilepsy in kids with febrile seizures
2.4% risk of epilepsy by age 25, double average risk
Invasive infection of the subarachnoid space
Meningitis (can cause fever and seizures)
how does meningitis occur
usually by hematogenous spread from the upper respiratiory tract,
or direct inoculation from sinusitis,
mastoidits or otitis media or skull fracture
The younger the child, the _____ likely he or she is to exhibit the classic symptoms of fever, headache, and meningeal signs.
- The younger the child, the less likely he or she is to exhibit the classic symptoms of fever, headache, and meningeal signs.
Neonatal meningitis associated with
Neonatal meningitis associated with maternal infection or pyrexia at delivery
Younger than 3 months, nonspecific symptoms of meningitis include
Younger than 3 months, nonspecific symptoms, including hyperthermia or hypothermia, change in sleeping or eating habits, irritability or lethargy, vomiting, high pitched cry, or seizures
Meningismus and a bulging fontanel may be observed but are not needed for diagnosis
as well as ____ irritability
paradoxical
child is irritated wehn you touch them
after 3 mos of age typical sxs associated with meningitis include
a. Fever
b. Vomiting
c. Irritability
d. lethargy, or any change in behavior
2-3 yrs of age typical sxs associated with meningitis include
a. headache
b. stiff neck
c. photophobia
d. Course may be brief and fulminant ( N. meningitidis) or gradual
in young infants with meningitis sxs are
a. specific findings are rare
b. May be febrile or hypothermic
c. Bulging fontanelle, diastasis of skull sutures, nuchal rigidity are late signs.
toddlers and children with meningitis usally present like
a. Meningeal signs
b. headache
c. nuchal rigidity
d. positive Kernig or Brudzinski’s sign
e. Focal neurological signs
f. Seizures in 30% of cases
g. Obtundation or coma in 15-20%
h. Petechial-purpuric rash
Petechial-purpuric rash is usually
(found with Neiserria meningitis)
non blanching
i. < 3mm red spots that don’t blanch when compressed
labs for meningitis
- Complete blood count (CBC) with differential
- Blood cultures
- Coagulation studies
- Serum glucose
- Erythrocyte sedimentation rate (ESR)
- Electrolytes
- Serum and urine osmolalities
- Bacterial antigen studies can be performed on urine and serum. They are mostly useful in cases of pretreated meningitis
why are head CTs done for meningitis
a. Focal neurological signs
b. To rule out other pathology
c. Does not rule out increased intracranial pressure
how should the patient be positioned for a LP
knees are lined up directly and directly vertical
shoulders lined up
hyper flex
advance needle slowly without the stylette
what are you looking for in a LP of a child suspected of having meninigitis
a. Measure opening pressure
b. Cell count
c. Gram stain
d. Culture and sensitivity
e. Glucose
f. Protein and antigen
g. Acid-fast bacillus
h. Fungal stains
age range of epiglottitis
ii. Age range 1-6 years
history of epiglottitis
- Acute onset of fever and sore throat
- Dysphagia
- Distress
- Drooling
- Cough is rare
Exam of epiglottitis
- toxic appearing
- Sniffing position
- Muffled voice
- Stridor
- Lymphadenopathy
what to do if you think it is epiglottitis
DO NOT STICK A TONGUE DEPRESSOR IN AND LOOK IN THEIR EFFIN THROAT
- Intubate in OR
- Admit to ICU
- IV abx
- Steroids not proven
late signs of epiglottitis
Oximetry, hypoxia and cyanosis are late signs.
other respiratory issues you see commonly in winter
age range
croup
with noisy audible breathing
ii. Age range: usually 3 months- 3years
airway managrement for epiglottitis and tx
assemble a team that can manage airway
- Fiberoptic naso-tracheal intubation, in the OR
- Rapid Sequence Intubation, orotracheal, in the ER
- Needle crico-thyrotomy if intubation fails
- Long slow breaths if bag valve mask used prior to intubation
- Disposition
- Intubate in OR
- Admit to ICU
- IV abx
- Steroids not proven
hx seen with croup
- Gradual onset of URI symptoms
- Rhinorrhea
- Cough, barking like a seal
- Fever
- Stridor, often resolves by time of ED presentation.
exam with croup
- Generally non toxic
- May be playful and cooperative or restless and anxious
- Stridor: inspiratory > expiratory
treatment for croup
- Cool mist
- Racemic epinephrine
- Dexamethasone 0.6mg kg IM or PO (same efficacy), some authors recomend repeat dose in 6 hrs.
- Nebulized Budesonide
Consultation/Admission, consider Intubation if for croup if
- Hypoxia, cyanosis
- Retractions unrelieved by initial treatment
- Diminished breath sounds, diminished stridor
- Change in mental status
home care for croup
- Tobacco/irritant free environment
- Vaporizer
- Cool night air
- Antipyrexia
RPA
Retropharyngeal abscess
Bacterial infection of retropharyngeal space leads to abscess formation and airway obstruction
what are we concerned abotu with RPA
ii. Can progress to mediastinitis (50% mortality), pericarditis, jugular vein thrombosis, carotid artery erosion, sepsis.
Hx of the patient with RPA
- Sore throat
- Odynophagia
- Fever
- Neck stiffness
- Neck swelling (97% in infants)
- Cough (33% in in infants)
exam findings with RPA
- Neck mass (91%)
- Cervical adenopathy (83%)
- Fever (86%)
- Neck stiffness (59%)
- Retropharyngeal bulge (43% - do not palpate in children)
- Agitation (43%)
- Lethargy (42%)
- Drooling (22%)
- Torticollis (18%)
- Respiratory distress (4%)
- Stridor (3%)
tx for RPA
- Admission/Consultation
- IV abx
- Intubate if respiratory distress
- ENT will decide wether to I&D (in OR) or not
Retropharyngeal space should measure
6 at 2 and 22 at 6
look at these XRAYS
flat faced coin on CXR
esophagus
trachea rings trap it like thi
Coins that fail to pass into the stomach can be removed
by a foley catheter under fluroscopy, or by endoscopy
why are button batteries bad
will short out and erode through tissues
neonates suspected of PNA
- grunting, flaring nostrils, tachypnea, and retractions
- lethargy, poor feeding, or irritability
- Cough is rare
- Fever may be absent (may be hypothermic)
DO NOT COUGH
this type of PNA is most commonly seen 24 hrs after birth
Beta Strep likely if within 24 hours of birth
this type of PNA is most commonly seen in the 2nd or 3rd week of life
Chlamydia pneumonia with conjunctivitis in 2nd or 3rd week
Infants PNA presentation
- Cough
- Preceding URI
- grunting, flaring, tachypnea, retractions
- lethargy; poor feeding; or irritability
- Bacterial, usually feberile
infants sxs of PNA
- Cough
- Preceding URI
- grunting, flaring, tachypnea, retractions
- lethargy; poor feeding; or irritability
- Bacterial, usually feberile
toddlers and small children have these sxs with PNA
- Cough
- Preceding URI
- Vomiting (post-tussive emesis)
- Abdominal pain
- Fever
sxs and pathogens in children with PNA
- Atypical pathogens, Mycoplasma, more common
2. May have other constitutional symptoms such as headache and pleuritic chest pain
boiling in the chest
bronchitis
astham like at the bronchioles
hx of a pt with bornchitis
- Preceding URI
- Fever
- Increased work of breathing
- Vomiting, especially post-tussive
- Irritability
- Poor feeding or anorexia
increased work of breathing in a child with bronchitis most commonly looks like
a. Wheezing
b. Cyanosis
c. Grunting
d. Noisy breathing
exam for bronchitis can look like
- Tachypnea, up to 50-60 breaths per minute (most common physical sign)
- Tachycardia
- Fever, usually in the range of 38.5- 39°C
- Mild conjunctivitis or pharyngitis
- Diffuse expiratory wheezing
- Nasal flaring, intercostal retractions
- Cyanosis
- Inspiratory crackles
- Otitis media
- Apnea, especially in infants younger than 6 weeks
- Palpable liver and spleen from hyperinflation of the lungs and consequent depression of the diaphragm
labs for bronchiolitis
- CBC: seldom useful
- Urine specific gravity: possible dehydration.
- Serum chemistries: gauging severity of dehydration.
- ABG may be needed in the severely ill patients
- Specific viral test for RSV helps confirm diagnosis but not essential.
CXR fir bronchiolitis can look like
- Hyperinflation and patchy infiltrates may be seen.
These findings are nonspecific and may be observed in asthma, viral or atypical pneumonia, and aspiration. - Focal atelectasis
- Air trapping
- Flattened diaphragm
- Increased anteroposterior diameter
- Peribronchial cuffing
why would you get a CXR for bronchiolitis
ay also reveal evidence of alternative diagnoses, such as lobar pneumonia, congestive heart failure, or foreign body aspiration.
TX for bronchiolitis
- Pulse oximetry monitoring
- Respiratory support
- O2, cool mist
- Nasal suction = best tx
- Supportive care
- Comfort
- Hydration
- Antipyrexia, analgesia
admissions criteria for bronchiolitis
- Oxygen saturation less than 94% after therapy. Some say less than 92%
- Respiratory distress (eg. respiratory rate >60/min or retractions at rest)
- Apnea or risk of apnea
- Age younger than 2 months or history of prematurity
- Underlying cardiopulmonary disease or immunosuppression
signs of resp distress in children
i. Grunting
ii. Flaring
iii. Severe tachypnea
iv. Retractions
v. Low O2 saturation
vi. Severe distress not responsive to supplemental O2?
1. Get help and prepare to intubate
signs of pyloric stenosis
i. History
1. Occurs by 3rd week of life
2. Projectile vomiting after feeding
3. Hungry
4. Failure to gain weight
5. Progresses to dehydration
ii. Hypochloremic, hypokalemic metabolic alkalosis.
PE with pyloric stenosis
- Signs of dehydration(hyprochloremic hypokalemic metabolic acidosis.)
- Palpable “olive” near lateral edge of right rectus, inferior to liver, is diagnostic
- Ultrasound if “olive” not palpated (20% false negative)
- Barium swallow
i. Most common cause of intestinal obstruction age 3mo-6yrs
b. Intussusception
who gets intussusception
ii. male:female = 4:1
sxs of intussusception
iii. Episodic abdominal pain, increasing severity and frequency
iv. Currant jelly stools in 50% (dark yellow)
i. Acute onset of billius vomiting, distension, pain.
c. Midgut volvulus
bilious vomit it the key here
c. Midgut volvulus most commonly seen
ii. 50% in 1st month; 90% in first year
Plain films may see “coffee bean sign” or “birds beak”, likely need this
midgut vovulus
ct or crontrast study
Surgery is needed emergently as bowel becomes ischemic, necrotic and perforates.
Infantile colic
i. Infant that feeds normally has episodes of crying and drawing up legs.
ii. Parents will attribute to abdomen but pt without vomiting or diarrhea
Infantile colic usually resolves by
iii. Usually resolves by 10 weeks. Look for other causes: abuse, constipation,volvulus,corneal abrasion, hair tournequet, GERD or anal fissures.
IT CRIES
b. Infection - any kind (look for fever, infectious sx)
c. Trauma - including abuse (know your infant milestones)
d. Cardiac - SVT, sweating with feeds, FTT, poor feeding
e. Reflux & Reaction to meds
f. Immunization site & Intussisception
g. Eyes - corneal abrasions (do fluorescein staining)
h. Strangulation/Surgical causes - hair tourniquets, torsion, intussisception (check the fingers/toes, take off the diaper)
presentation
- Anorexia, vomiting
- Periumbilical pain, migrates to RLQ, becomes diffuse after rupture
- Limp
- RLQ tenderness and peritoneal signs
- Leukocytosis, ketonuria
iv. Pitfalls - Pt may have normal WBC count
d. Torus fx
review XRAYS
needs to be immobilized
part of the cortex remains intact in this type of pediatric fx
e. Greenstick fx
we have a _____ threshold for ordering x- rays than adults
lower threshold
nursemades elbow is also knwon as
subluxation of the radial head
how does a nursemades elbow occur
i. Caused by distraction of the arm in extension
children with a nursemades will present with
iv. Refuses to use injured arm
v. Held in pronation, and extension
would you need imaging in a nursemaids elbow
vii. Imaging is not needed if history and exam is typical
if no one saw what happened
viii. X ray tech likely to reduce while positioning for film
how to fix a nursemades elbow
thumb on radial head supinate and pull it up
if the class method does not work
keep it pronate and pop it up
g. Slipped Capital Femoral Epiphysis seen most commonly in this population
Age 12-15 in boys,
10-13 in girls
often heavy but not always
pain seen with
slipped Capital Femoral Epiphysis
iii. Presents with hip and groin pain, knee pain
iv. Abnormal gait, external rotation
kids with SCFE can’t
v. Unable to press thigh against abdomen
XRAY for SCFE
scoop of ice cream fallen off the cone lOOK CLOSE
like you are about the shave off the grater trochanter from the head of the femur
should come up to the line
mangement of a SCFE
- Admission
- Consultation
- Absolute non-weight bearing
- Surgery
Transient Tenosyovitis of the Hip is seen as
- Acute or gradual onset of abnormal gait
Transient Tenosyovitis of the Hip seen in what population
- Under 10 years old
pain associated with Transient Tenosyovitis of the Hip
- Hip, thigh and knee pain
4. Tenderness over anterior hip
lab diagnostics associated with Transient Tenosyovitis of the Hip
- X-rays normal or show hip joint effusion
- Normal or slightly high wbc and esr
r
how to handle scrotum in zipper
cut zipper at open end with clippers
tx for transient Tenosyovitis of the Hip
- Supportive treatment and re eval in 2 weeks
septic joint seen with
ii. Septic joint
1. Esr>20, CRP >2mg/dl, wbc>12
2. Non weight bearing
3. Fever
occult bacteremia in a child 3-6 months
what can pnumococcal bactermia progress to
a. FWS with temp 39.5 (103.1f)
b. Positive blood culture in <1% if WBC <15k
c. Positive blood culture in 10% if WBC > 15k
3% of cases of Pneumococcal bacteremia progress to meningitis
what is effective prevention of pneumococcal disease
Heptavalent pneumococcal vaccine, Prevnar, is effective in preventing invasive pneumococcal disease.
signs of dehydration
hyprochloremic hypokalemic metabolic acidosis.)
normal VS for infant
30-50 RR
120-160 hr
normal VS infant
20-40 RR
80-140 HR
Occult bacteremia (kid has a fever but you can’t find it)
what pathogens would you suspect in infants
a. H. influenzae type b
b. N. meningitidis
c. S. pneumoniae
Occult bacteremia (kid has a fever but you can’t find it) what pathogens would you suspect in older children
a. N. meningitidis
b. Group A beta hemolytic Strep.
PE findings with bacteremia
No consistantly present findings on history or exam, except for fever.
Temp <39C –> low likelihood of positive blood cultures.
sxs of tracheobronchial Foreign Bodies
i. 50% show air trapping
ii. 12% atelectasis
iii. 18% signs of infection
iv. 24% normal
v. Suspected Respiratory FB may need CT or bronchoscopy to confirm the dx
